Lotus Life LLC | SimplePractice

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Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Gender

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Trauma/PTSD Neurodivergence (ADHD, autism) Religious trauma Grief or loss Family wounds Other

What brings you to therapy right now?

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Billing & Payment

Insurance details

I am currently only in network with Aetna and United. If I am out of network with your insurance I can provide a superbill for you to submit to your insurance.

I would like to use my Aetna insurance. I would like to use my United Healthcare insurance. I will be paying out of pocket. I am not sure about my insurance.

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.